Classifying and measuring thermal burns in the ED will dictate all of the treatment decisions that follow:

• First degree, second degree, third degree burns: How can you tell?
• How should you calculate the total body surface area of burns?
• IV fluids: what kind and how much? How can you tell when you've given the right amount?
• Wound care: when should you debride blisters, and should you use silver dressings?
• Escharotomy: when must it be done?
• Was it really an accident or was it abuse?
• Referral: How do you know when to refer a patient to a burn center?

Abstract

Thermal burn injuries are a significant cause of morbidity and mortality worldwide. In addition to treatment of the burns, emergency clinicians must assess for inhalation injury, exposure to toxic gases, and related traumatic injuries. Priorities for emergency resuscitation include stabilization of airway and breathing, intravenous fluid administration, pain control, and local wound care. Special populations, including children and pregnant women, require additional treatment considerations. Referral to specialized burn care for select patients is necessary to improve long-term outcomes. This article reviews thermal burn classification and evidence-based treatment strategies.

Case Presentations

A 35-year-old chef presents to the ED after burning his right hand on a cooking surface at work. His vital signs are normal and his hand is blistered over half of the palmar surface. You place a nursing order for pain medication and a tetanus booster. As you leave the bedside, you try to recall whether he should be referred to a burn center and whether there are any evidence-based guidelines to help you select a dressing…

As you put down his chart, the nurse calls you to the resuscitation bay for a 22-year-old woman brought in by EMS from a house fire. Paramedics report that she required extrication from the collapsed house. She is minimally responsive, with soot visible in her oropharynx and extensive burns to her abdomen, back, and right upper extremity. Her vital signs are: temperature, 37.5°C (99.5°F); heart rate, 140 beats/min; blood pressure, 85/40 mm Hg; respiratory rate, 35 breaths/min; and oxygen saturation, 88% on room air. As you prepare to intubate her and start IV fluid resuscitation for her hypotension, you wonder which resuscitation fluid you should select and how to best monitor the patient’s response. You wonder whether anything other than her extensive burns may be causing her hypotension and altered mental status…

Your next patient is a 3-year-old boy brought in by his mother for scald burns to his feet. The mother says that yesterday the child picked up a bowl of hot soup and accidentally spilled its contents. He appears fussy and has symmetric, well-demarcated, full-thickness burns to both feet from the ankles down. His vital signs are: temperature, 37°C (98.6°F); heart rate, 120 beats/min; blood pressure, 90/55 mm Hg; respiratory rate, 22 breaths/min; and oxygen saturation, 98% on room air. You are concerned about the delay in seeking care and wonder whether this might be more than an accidental burn…

Introduction

The American Burn Association (ABA) reports that nearly half a million people suffer thermal burns each year in the United States.1 According to World Health Organization estimates, as many as 265,000 people worldwide die annually of thermal burns.2 The economic burden of thermal burn injury is also substantial: In the United States in 2000, the annual direct-care cost of treating pediatric burns alone was $211 million.2 This does not take into account the economic impact of rehabilitation and long-term disability. Efforts to prevent thermal burns through regulation and public health initiatives have reduced the incidence in developed countries; however, burn injuries still account for approximately 0.5% of all United States emergency department (ED) visits annually.3 This issue of Emergency Medicine Practice reviews the guidelines on assessment of burns and how these assessments are used for optimal management of fluid resuscitation, in addition to the latest evidence on burn-wound care, pain control, and the criteria for referral to specialized care.

Critical Appraisal of the Literature

A literature search was performed in PubMed using the search terms burn, burns, and inhalation burn. The search identified approximately 4600 original articles that were screened and narrowed to articles of highest quality evidence and relevance. Only articles with abstracts available in English were included.

The Cochrane Database was searched for systematic reviews using the key term burn, which identified 11 articles. A search of the Database of Abstracts of Reviews of Effects (DARE) and Center for Reviews and Dissemination (CRD) databases did not reveal any unique publications not previously identified in the PubMed search. A search of the National Guidelines Clearinghouse identified 1 relevant guideline. The ABA Consensus Guidelines (2012) and ABA Practice Guidelines: Burn Shock Resuscitation (2008) were also reviewed. The former is a consensus statement, whereas the latter identifies the level and category of evidence upon which each of its recommendations is based. International guidelines from the World Health Organization and the European Burn Association were also reviewed.

Overall, the clinical evidence on thermal burns is of moderate strength, consisting of relatively few large, well-designed clinical trials and many smaller trials and observational studies. When possible, recommendations in this article are evidence-based. Recommendations based on common practice or expert consensus are explicitly noted as such.

Risk Management Pitfalls for Management of Burn Patients in the Emergency Department

2. “I gave prophylactic oral antibiotics to a patient with a partial-thickness burn. The patient had an allergic reaction, and now my colleagues are saying that I should have never given the antibiotic in the first place.”

Systemic prophylactic antibiotics do not benefit burn patients. Use topical dressings for local wound care. Treat with systemic antibiotics only if a clinically apparent infection develops.

5. “I thought that fluid-resuscitating the patient according to the Parkland formula during the 8 hours he was awaiting transfer in my ED was enough. I didn’t realize he wasn’t making any urine.”

Use clinical endpoints, such as urine output, to assess and guide IV fluid administration. Formulas are merely a guideline, and IV fluid administration may need to be decreased or increased depending on how the patient responds.

6. “I assumed the patient was hypotensive due to the extensive burns he sustained in the house fire. I didn’t consider that he might have intra-abdominal hemorrhage.”

Burn patients are at risk for traumatic injuries and should undergo a comprehensive trauma survey and diagnostic testing per Advanced Trauma Life Support guidelines.

Tables and Figures

References

Evidence-based medicine requires a critical appraisal of the literature based upon study methodology and number of patients. Not all references are equally robust. The findings of a large, prospective, randomized, and blinded trial should carry more weight than a case report.

To help the reader judge the strength of each reference, pertinent information about the study is included in bold type following the reference, where available. In addition, the most informative references cited in this paper, as determined by the authors, are noted by an asterisk (*) next to the number of the reference.

First-degree burns are superficial and involve only the epidermis. Second-degree burns are partial thickness and involve the dermis. Third-degree burns are full-thickness and invade subcutaneous structures.

If prehospital cooling has not been initiated, de­layed cooling in the ED may still be helpful.

Physical examination findings are the only way for emergency clinicians to classify burns; however, they are only moderately reliable for estimating burn depth.

Treat empirically for inhalation-related toxicity in unstable patients and those with altered mental status.

When there is concern for cyanide toxicity from smoke inhalation, administer hydroxocobalamin 5 g IV. This is preferred over sodium nitrite and sodium thiosulfate.

The Lund and Browder Chart should be used to estimate total body surface area (TBSA) burned. Other measurement methods (eg, rule of nines) are less accurate, particularly in children.

Patients with > 20% TBSA burns rapidly become volume depleted. Use the Parkland formula (www.mdcalc.com/parkland-formula-burns) or modified Brooke formula to resuscitate with a crys­talloid fluid, such as lactated Ringer’s solution.

Titrate fluid resuscitation to a urine output of 0.5-1 mL/kg/hour in adults and 1-1.5 mL/kg/hour in children.

All wounds should be irrigated, and devitalized tis­sue needs to be debrided.

Partial-thickness burns require a dressing. Avoid silver-based dressings, as they are associated with longer healing time.

Emergent escharotomy should be considered if there is absent or decreased pulse oximetry, absent or decreased pulses, elevated compartment pres­sures, or new-onset neurologic deficits.

There is insufficient evidence to recommend either prophylactic antibiotics or antibiotic wound dress­ings in burn patients.

Be aggressive in the treatment of pain related to burns; opioids are typically used.

In children, consider the possibility of nonacci­dental injury when their presentation to the ED is delayed or when burns are symmetrical, have clear upper wound margins, or appear with old or unrelated injuries.

Agarwal P, Sahu S. Determination of hand and palm area as a ratio of body surface area in Indian population. Indian J Plast Surg. 2010;43(1):49-53. (Prospective study; 600 patients)DOI: http://dx.doi.org/10.4103/0970-0358.63962

Thermal burn injuries are a significant cause of morbidity and mortality worldwide. In addition to treatment of the burns, emergency clinicians must assess for inhalation injury, exposure to toxic gases, and related traumatic injuries.

This month’s corresponding full-length journal issue of Emergency Medicine Practice was authored by Dr. Juliana Tolles of the David Geffen School of Medicine at UCLA and was edited by Dr. Boyd Burns of the University of Oklahoma school of Community Medicine and Dr. Christopher Palmer of Wash U.

It is important to remember that all resuscitation formulas should only be used as guides. Patients should be assessed frequently, with individual adjustments made to maintain adequate organ perfusion.

Blumetti et al (2008) conducted a retrospective study of patients resuscitated with the Parkland formula at a single institution over 15 years to determine the accuracy of the formula in guiding resuscitation. Using urine output as a guideline for adequate resuscitation, they found that patients commonly received fluid volumes higher than predicted by the Parkland formula, and concluded that the formula should represent a resuscitation “starting point,” but urine output is the most important parameter to control resuscitation volume.

Cartotto et al (2002) performed a retrospective study, and also found that the Parkland formula underestimated the volume requirements in most adults with burns, especially in those with large full-thickness burns. Thus, the Parkland formula is a validated and effective approach to initial fluid resuscitation in the acutely burned patient (Baxter 1974, Cartotto 2002, Blumetti 2008).

Date of Original Release: February 1, 2018. Date of most recent review: January 10, 2018. Termination date: February 1, 2021.

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